Name of patient:                     Sex: Male Female

Address: 

Home Phone:   Business Phone:

Male Head:  Last Name:  First Name:  Birth Date:

Social Security # :  Employer name:

Employer Address:   Employer Phone:

Dental Insurance Co:  Group # :  Agreement # :

Female Head:  Last Name:  First Name:  Birth Date:

Social Security # :  Employer name:

Employer Address:   Employer Phone:

Can we please have the name, address and phone number of a friend or neighbor who can be reached in case of emergency?

Name & Address:  :    Phone:

Are there any other children in your family? Please list their names:

The policy in our office is the parent who requests treatment for the child is responsible for all fees for services rendered.

Date:       Signature of parent requesting care_____________________________________

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